Between the beginning of May and the first week of August, there have been more than 33 000 excess deaths in South Africa. This is more than three times the number of confirmed Covid-19 coronavirus deaths. Kathryn Cleary asked the experts what we do and do not know about what so many people are dying of.
Data released on Wednesday by the SA Medical Research Council’s Burden of Disease Research Unit suggests that parts of the country may have reached a peak in Covid-19 infections by the end of July, which could potentially signal a downturn in the country’s epidemic.
Excess deaths, in other words, natural deaths that have occurred over and above what would be expected based on historical patterns, declined from the last week of July to the first week of August.
The tally of excess deaths between the beginning of May and the first week of August stood at 33 478, while reported Covid-19 deaths totalled nearly 9 000 on August 4 (the latest date covered in the excess deaths report).
This leaves more than 24 000 deaths unaccounted for as of August 4.
Professor Debbie Bradshaw, chief specialist scientist from the research unit, tells Spotlight that they do not yet know the medical causes of these deaths – or if they are related directly or indirectly to Covid-19.
Part of the problem is simply that information has not yet been captured.
When a person dies, a doctor must complete a death notification form showing the medical cause of death.
Legally, if a doctor cannot confirm the cause of death, a post-mortem must be done (or can be requested by the family).
This notification form is used by the family or their undertaker to register the death with the department of home affairs, explains Bradshaw.
“Once home affairs has completed the verification of the information, they send the forms to StatsSA to code and capture the cause of death information. The system is labour intensive and there is a backlog in the production of cause of death statistics. We have suggested to government that they fast-track the processing of such information to provide insight into the actual causes of death,” she says.
Using information from the National Population Register which is provided to Bradshaw and her colleagues on a weekly basis, the research council’s weekly excess death reports are compiled to shed light on mortality during the Covid-19 pandemic.
Their projections take into account persons who are not on the population register and deaths that may not have been registered with the department.
The projections also do not include data on deaths for children under the age of 1 as a result of birth registrations being put on hold during level 5 of the lockdown.
Possible causes of death
While confirmed causes of these deaths are not yet known, Bradshaw says that the geographic time trend and age patterns of the excess deaths indicate that a high proportion of them are likely to be due to Covid-19.
However, there is no way to be certain of this without further investigation.
“The question is, is it due to Covid-19 directly or due to indirect effects of the lockdown?” asks Professor Landon Myer, director and head of the school of public health and family medicine at the University of Cape Town.
“It’s almost certainly a mix of the two. It would be implausible to think that we are detecting every death caused by Sars-CoV-2, but it’s not clear to me that all deaths with Sars-CoV-2 detected are deaths due to Sars-CoV-2,” he says.
Myer argues that the indirect effects of the lockdown on mortality could be significant.
This could be because of the negative effects on access to healthcare services such as clinics or acute care services or changes in health seeking behaviours of people requiring health care.
“I think that the number of different ways that you could die from reduced access to health services is massive. The different routes to death are considerable and it’s not just HIV, TB or [lack of] vaccinations. It’s all those things put together. But the actual data to say that, to my knowledge, is incredibly limited,” he says.
Acute rather than chronic
Looking deeper, Myer says that the causes behind some of these excess deaths could be acute health issues, such as a heart attack, stroke or acute asthmatic attack.
While deaths related to HIV, diabetes or other chronic diseases cannot be ruled out, these deaths might take more than a few weeks to reflect in excess death statistics.
“We’ve seen this increase in excess deaths within weeks. But generally if you’re living with HIV and are on antiretrovirals (ARV) and you’re relatively healthy, and you stop taking your ARVs, it could be months to years before you die. Certainly not weeks,” says Myer.
Not seeking care
Bradshaw notes that the excess deaths may be linked to people not presenting at primary healthcare facilities due to fear of Covid-19 or other anxieties, and a potential for deaths due to chronic or acute conditions unrelated to the virus.
“[We] are exploring whether it is possible to work with the department of health to evaluate mortality trends of the patients who are being treated for selected chronic conditions,” she says.
When asked about the status of those defaulting on treatment during lockdown and the implications for excess deaths, director for TB, HIV and drug-resistant TB in the health department, Dr Norbert Ndjeka, could not provide Spotlight with any answers.
Ndjeka, however, provided data that show a severe drop in the number of drug-resistant TB cases that are being detected.
In June last year, 753 new cases of drug-resistant TB were reported. In June this year, only 284 were reported.
Determining the possible causes of death
To further investigate the causes of these excess deaths, Bradshaw says they are exploring the possibility of combining data sources to get a better assessment of Covid-19 related deaths.
“We are in discussion with the National Institute for Infectious Disease and the national department of health about how we can link data sources to get a more accurate set of information. Secondly, we think that there may be scope to use a verbal autopsy interview with the next of kin to get information about the disease progression that their loved one experienced,” she says.
Not just in SA
While South Africa’s 33 000 excess deaths so far may seem like a lot, the country’s situation is not unique.
Reporting by The New York Times suggests that by the end of July, globally, there were over 161 000 Covid-19 deaths unaccounted for in official death numbers.
A Financial Times analysis previously estimated that globally Covid-19 deaths may be around 60% higher than the reported numbers – with wide variation between countries.
“Another issue is that we do not really understand what’s going on with Covid-19 in the population generally,” says Myer.
“Could there be much more Covid-19 in South Africa than we think, such that our reported cases are not necessarily accurate? If that was the case, maybe our excess deaths are not excess and [are in line] with the epidemic, except the epidemic is much more extensive than we think.”
*This article was produced by Spotlight – health journalism in the public interest.